- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,623.41 / $9,549.93
| Facility | | $4,365.16 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,238.72 / $3,890.45
| Professional | | $1,819.70 | $2,238.72 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $9,549.93
| Facility | | $1,513.56 | $4,365.16 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,162.28 / $4,570.88
| Professional | | $1,995.26 | $3,162.28 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $5,370.32
| Professional | | $2,238.72 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,344.23 / $13,489.63
| Professional | | $1,995.26 | $2,344.23 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,235.94 / $8,128.31
| Facility | | $1,047.13 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $5,011.87
| Professional | | $1,995.26 | $3,019.95 | $5,011.87 |